1. Advanced Restorative Dentistry
Dr Lamis Elsharkasi

2. Introduction
The concept of undergoing restorative therapy remained unchanged for many decades. It involved all measures by which the dentist can prepare the decayed hard tooth tissue to receive a restoration which maintains the tooth integrity, restores function, aesthetics and preserves the health of the masticatory system.
Later on, the scope of operative dentistry was then extended to involve all lesions affecting the hard tooth tissues, not only the carious involvement of a tooth but also other defects including fracture, erosion, abrasion, attrition, discoloration as well as the developmental and acquired defects

3. Introduction
The modern concept for restorative dentistry is based on conservation and has concentrated on the importance of prevention of diseases affecting hard tooth tissue and preservation of the sound tooth structure
 Restorative dentistry encompasses the prevention, diagnosis, interception, treatment and prognosis of defects of the hard tooth structure

4. Ideal features of restorative treatments
Resolve sensitivity
Restore function
Aesthetic
Have prove durability
Cause insignificant loss of tooth structure, i.e. are minimally invasive
Preserve dental hard tissue
Enhance periodontal health
Simple, quick, and tolerable to the patient

5. Advanced restorative techniques
Hydrochloric acid-pumice micro-abrasion technique
Non vital bleaching
Vital bleaching-chair-side and night guard
Localized composite resin restoration
Composite veneers-direct and indirect
Adhesive metal casting

6. Hydrochloric acid-pumice micro-abrasion technique
It is a controlled method of removing surface enamel in order to improve discoloration that are limited to the outer enamel layer
It is achieved by a combination of abrasion and erosion
Less than 100 mm of enamel is removed

7. Hydrochloric acid-pumice micro-abrasion technique
Indication:
Fluorosis
Idiopathic speckling
Post-orthodontic treatment demineralization
Prior to localized composite restoration or veneer placement for well demarcated stain
Turner teeth – white or brown surface staining

8. Hydrochloric acid-pumice micro-abrasion technique
Perform preoperative vitality tests, radiographs and photographs
Clean the tooth with pumice and water and dry
Isolate the tooth with rubber dam
Mix 18% hydrochloric acid with pumice into a slurry

9. Apply small amount to the labial surface for 5 seconds using either a rubber cup or wooden stick
Could be repeated for up to a maximum of 10 application per tooth
Remove the rubber dam
Apply fluoridated tooth paste for 1 minute
Review in a month

10. Hydrochloric acid-pumice micro-abrasion technique
Advantages:
The appearance of treated teeth are improved with time
Minimal enamel layer is removed-minimally invasive
No association with pulp damage
Technique is easy to perform for dentist and patient
Removal of any mottled area is permanent
Failure to improve the appearance with micro-abrasion has no harmful effect and make it easier to mask some lesions with composite restoration or veneers.

11. Non-vital bleaching Indications:
This technique describes the bleaching of teeth that have become discoloured by the diffusion into the dentinal tubules of haemoglobin breakdown products from necrotic pulp tissue
Bleaching agent: sodium perborate, hydrogen peroxide, carbamide peroxide
Indications:
Discoloured non-vital teeth
Well-condenced gutta percha root filling
No clinical or radiographic signs of periapical disease

12. Non-vital bleaching Technique: Preoperative radiograph
Clean the teeth with pumice
Record the shade of the discoloured tooth
Place rubber dam
Remove palatal restoration and pulp chamber restoration
Remove root filling to 1 mm below dentogingival junction
Place 1mm of cement over the gutta percha
Gently freshen dentine with round bur

13. Etch the pulp chamber with 37% phosphoric acid for 30-60 seconds, Wash, dry
Place bleaching agent into pulp chamber
Place dry cotton over the mixture
Seal the cavity with GIC
Repeat the process at weakly intervals until the tooth is bleached
Restore the tooth with composite

14. Vital bleaching-nightguard
This technique involves the daily placement of carbamide peroxide gel into a custom-fitted tray on either the upper or the lower arch
It is carried home by patient
Indication
Mild/moderate fluorosis
Single tooth with sclerotic pulp chamber and canals
Selective treatment for aesthetic purposes

15. Vital bleaching-nightguard
Technique:
Take an alginate impression of the arch to be treated and cast a working model in stone
Relieve the labial surfaces of the teeth on cast by 0.5 mm and make an acrylic pull down vacuum-formed splint as a mouth guard
The splint should be no more than 2mm thick and should not cover the gingiva

16. Give Instruction to the patient on how to perform a full mouth prophylaxis and how to apply the gel into mouth guard
Patient should use the splint for 4-6 hours daily for 2 weeks
Review in 2 weeks to check the patient is not experience any sensitivity and then by 6 weeks by which 80% of the change should be occurred

17. Localized composite resin restoration
This restorative technique is used to replace defective enamel with a restoration that bonds to and blends with enamel
Indication
Well demarcated white, yellow, or brown hypo-mineralized enamel (MIH)

18. Localized composite resin restoration
Technique:
Take preoperative photographs and select the shade
Apply rubber dam and contoured matrix strip if required
Remove full extend of demarcated lesion with a round diamond bur down to the amelo-dentinal junction
Etch, bond, the chosen shade of composite, use a rush lubricated with a bonding agent to smooth the surface, and light cure it.
Polish
Take post operative photographs.

19. Composite resin veneers
Although the porcelain jacket crown (PJC) may be the most satisfactory long-term restoration for a severely hypo-plastic or discoloured tooth, it is not an appropriate solution for children for two reasons:
The large size of the young pulp horns and chamber.
The immature gingival contour.

20. Composite resin veneers
Composite veneers may be direct( placed at initial appointment) or indirect( placed in subsequent appointment having been fabricated in the laboratory).
Most composite veneers placed to children and adolescents are of direct type
Conservative veneering methods may offer not just a temporary solution, but a satisfactory long-term alternative to PJC.

21. Composite resin veneers
Indication:
Discolouration
Enamel defects
Diastema
Mal-positioned teeth
Large restoration
Relative contraindication:
Insufficient tooth tissue available for bonding
Oral habits.
occlusal factors

22. Composite resin veneers
Technique
Use a tapered diamond bur to reduce labial enamel by mm if appropriate
Identify the finish line at the gingival margin and also mesially and distally just labial to the contact points
Isolate the tooth with rubber dam

23. Etch, bond.
Use opaquer if the discoloration is intense
Apply composite resin of the desired shade with a plastic instrument, use contour strip crown
Finish the margins with diamond finishing bur and interproximal finishing strips.

24. Composite resin veneers
Types of veneer preparation:
Feathered incisal edge
Incisal bevel preparation
Intra-enamel or window preparation
Overlapped incisal edge preparation

25. Adhesive metal castings
The fabrication of cast occlusal onlays can be done for posterior teeth and palatal veneers for incisors and canines
These restoration are manufactured with minimal or no tooth preparation.
Indications:
Amelogenesis imperfecta
Dentinogenesis imperfecta
Dental erosion, attrition, or abrasion
Enamel hypoplasia

26. Adhesive metal castings
Technique:
Obtain study model
Perform a full mouth prophylaxis
Ensure good moisture isolation
Place a retraction cord into the gingival cervices of the teeth to be treated
Take the impression

27. Costract cast onlays a maximum of 1
Costract cast onlays a maximum of 1.5mm thick occlusally in either nickel-chrome or gold
Cement onlays
Check occlusion
Review

28. Key points
The management of children with advanced restorative problems should be viewed as a long-term commitment
Identification of the aetiology of tooth discoloration is essential for selecting the most appropriate treatment technique
Advanced restorative problems in children should be treated conservatively as possible

29. Key points
Micro-abrasion should be the first treatment option in all cases of enamel surface discoloration
Maintenance of occlusal face height is essential in patients wih amealogenesis or dentinogenesis imperfecta